APPLICATION FOR ARCHITECTS & ENGINEERS
PROFESSIONAL LIABILITY COVERAGE
IMPORTANT INSTRUCTIONS: Please:
1. Answer all questions completely.
Underwriting Managers and Program Administrators Two Wisconsin Circle
Chevy Chase, MD 20815-7022 (301) 961-9800 Fax: (301) 951-5444 2. If there is insufficient space to complete an answer,
continue on a separate sheet of your firm’s letterhead. Indicate the question number.
3. This form must be completed, signed, and dated by a principal, partner, or officer of your firm.
4. Mail completed application to your local broker or agent.
NOTE:
The insurance coverage for which you are applying is written on a CLAIMS-MADE policy. Only claims which are first made against you during the policy period are covered, subject to policy provisions. “Claims” means the receipt of a demand for money or services, naming “you” and alleging a “wrongful act.”
New Application Renewal Application
Renewal Policy # The limits of liability stated in the policy are reduced by the cost of defense. Legal defense costs also may be
Schinnerer Use Only applied against your deductible, if applicable to the claim. If you have any questions about the coverage, please discuss them with your insurance agent.
Please check the limits (000’s) which you would like us to quote:
100 250 500 1,000 2,000 3,000 5,000 Other Please advise of the deductible(s) you wish us to quote:
FIRM INFORMATION
1. Firm Name:
Principle Address:
Street City
County State Zip Code
( ) ( )
Telephone Fax Number
E-Mail Address Website URL
(Please list addresses of all branch offices on a separate sheet and attach to this application.)
Is your firm a: (Please check as applicable)
Corporation Professional Corporation Partnership Sole Proprietorship Limited Liability Corporation Limited Liability Partnership
Tax ID Number: Year your firm was established
2. Number of Licensed Professionals:
Architects Engineers Land
Surveyors Landscape Architects Others All Total A. Principals, Partners,
Officers & Directors B. Staff
Full Time Part Time Temporary Leased
C. Number of Employees AGENT OR BROKER
One Park Plaza, Suite 600, Irvine, CA 92614-5789
Tel: 949-833-7125 Fax: 949-833-7127 [email protected]
3875 Hopyard Rd., Suite 240 Pleasanton, CA 94588 Tel: 925-416-7862 Fax: 925-416-7869
1775 Hancock Street, Suite 180 San Diego, CA 92110
Tel: 619-574-6220 Fax 619-574-6288 [email protected]
Status Yes No License No. Status Yes No License No.
Licensed CNA Agent (Casualty Lines)
Licensed Casualty Agent with Company Other Than CNA
Licensed Broker X 0E67768 Non-Resident (If Applicable)
3. Please show the number of employees who left the firm in the past 12 months:
A. Management: B. Professional Staff:
4. Please attach current brochure describing your firm’s services. If you don’t have a current brochure, describe the nature of your practice.
RISK MANAGEMENT AND LOSS PREVENTION
5. A. Does your firm follow written in-house quality control procedures?
B. Are all appropriate staff members familiar with these procedures?
Y Y
N N 6. Does your firm use an automated master specification system such as MASTERSPEC®
or SPECSystem™? If yes, percent of projects used on: %
Y N
7. A. Have any principals of the firm attended, during the last 12 months, a Risk Management Seminar presented by Victor O. Schinnerer & Company, Inc.? B. Have any of the firm’s employees completed the Victor O. Schinnerer & Company,
Inc. “Voluntary Education Program”? If yes, how many? __ _ employees C. Does your firm have an in-house program of continuing education for
professional employees? This would include attendance at AIA/NSPE/PEPP sponsored seminars and similar functions?
D. How many professional employees of your firm have had at least six hours of continuing education in the past 12 months?
Y
Y
Y
N
N
N
8. Has your firm participated in an “Organizational Peer Review” sponsored by ACEC and AIA?
Y N
If yes, when?
9. Does your firm have a Total Quality Management TQM program? Y N
10. A. Does your firm use written contracts on every project? If no, please provide us with the percentage of your past 12 months’ billings where oral agreements are used: %.
Y N
Describe the circumstances when oral agreements are used on a separate sheet. B. Please specify the approximate percentage of your firm’s professional services
rendered under AIA or EJCDC standard forms of agreement: %.
C. If non-standard contracts or modified AIA or EJCDC contracts or “letter” agreements are used, are they reviewed by your firm’s legal counsel for liability
implications prior to signing? Y N
11. Who from your firm should receive Schinnerer’s risk management publications, Guidelines for Improving Practice and Liability Update?
(Name/Title) 12. Please indicate professional society memberships:
The American Institute of Architects American Consulting Engineers Council American Congress on Surveying and Mapping
National Society of Professional Engineers American Society of Civil Engineers American Society of Landscape Architects Other (specify)
ACCOUNTING YEAR DATA
NOTE: Questions 13 through 20 refer to total gross billings, whether or not collected, for your firm’s past accounting year (12 months). (Newly formed firms should use estimated total gross billings for the next 12 months.)
13. Please provide your professional service billing information, including billings attributable to consultants. (Newly formed firms should use estimated total gross billings for the next 12 months.)
Most Recently Completed Fiscal Year
Second Most Recently Completed Year
Estimated Billings for Current Year Dates of Reporting Periods to to to A. Projects currently covered by
specific project policy. (Please provide the project name, location, construction values, current status, insurance carrier and limit of liability on a separate sheet.)
$ $ $
B. Feasibility studies, master plans, reports, opinions, non- structural interior design, abandoned projects, landscape architecture, land surveying (whether done by you or your consultants).
$ $ $
C. All Other Billings $ $ $
D. Direct Reimbursables (e.g. travel per diem, etc.)
$ $ $
E. Total Gross Receipts $ $ $
F. Total Construction Values
(If Known) $ $ $
14. If you currently have a specific additional limit of liability endorsement on your policy, provide us with your firm’s billings for the most recently completed fixcal year and estimated for current year in Question 13 for each
project: .
CLIENTS/PROJECTS/SERVICES DATA
15. Please indicate the approximate percentage of your total gross billings in Question 13E derived from each of the following categories of clients:
Federal Government % State Governments % Local Governments % Institutional % Industrial % Real Estate Developers % Lending Institutions % Contractors % Other Design Professionals % Other (Private) % Other (Public) % 16. Were more than 50% of all your total gross billings in Item 13E derived from a single client or contract? If yes,
specify client, projects, contract form(s), describe all services rendered and indicate how long you expect this relationship to continue in the space provided. Y N
17. Approximately, what percentage of your billings in 13E is derived from repeat clients? %. 18. Please provide the following information regarding your firm’s three largest current projects:
Name City/
State
Owner/ Client
Project Type
Services You Performed
Est. Total Construction
Cost
Total Gross Billings
19. Please indicate the approximate percentage of your total gross billings in Item 13E derived from each project type: (This section should equal 100%.)
Airports % Houses/Townhouses % Pools/Playgrounds % Amusement Rides % Industrial Waste Treatment % Potable Water Systems % Apartments % Jails/Justice % Recreation/Sports % Bridges % Landfills % Roads/Highways % Churches % Libraries % Schools/Colleges % Condominiums % Manufacturing/Industrial % Shopping Center/Retail % Convention Centers % Mass Transit % Storm Water Systems %
Dams % Nuclear/Atomic % Tunnels %
Harbors/Piers/Ports % Office Buildings % Warehouses % Hospitals % Parking Structures % Wastewater Systems % Hotels/Motels % Petro/Chemical % Wastewater Treat. Plants % Other (specify) % Other (specify) % Other (specify) %
20. As the approximate percentage of your firm’s net billings (total gross billings less billings for consultants), please indicate which of the following services were performed by your firm during your firm’s past accounting year.
Architecture % Civil Engineering %
Mechanical Engineering % Electrical Engineering %
Structural Engineering % Soils Engineering %
Laboratory Testing % Landscape Architecture %
Land Surveying % Construction/Project Management %
Process Engineering % Chemical Engineering %
Environmental Abatement % Marine Engineering %
Nuclear Engineering % Mining Engineering %
Machinery/Equipment Design % Oil/Gas Well Engineering % HVAC Engineering % Other (please specify) %
Total Should Equal 100%
21. Please indicate the approximate percentage of your total gross billings in Item 13E, if any, derived from the following categories:
Ground testing/Soils % Lead abatement or evaluation % Foundation/Substructure % Surveys of subsurface conditions % Falsework/Temporary construction % Continuing service or inspection contracts % (Except site shoring)
Inspections of home/commercial properties % Projects located outside U.S.,
its territories or Canada % for prospective buyers or lenders
Asbestos abatement or evaluation % Site preparation % NOTE: If you subcontract any portion of the above services, on a separate sheet please provide details of these
services, including whether the subcontractor is insured.
22. A. Has your firm performed or subcontracted to others in the past 12 months (or expect to perform or subcontract in the next 12 months) services in connection with:
Y N Industrial piping/processes Y N Air emission control systems Y N Hazardous/toxic disposal sites Y N Superfund sites
Y N Underground storage tanks Y N Solid waste sites
Y N Landfills
Y N Permitting/monitoring related to hazardous waste B. Has any claim been made or legal action been brought for a pollution or environmental
injury or damage in the past ten years (or made earlier and still pending against your firm, its predecessors, or employees?
Y N
C. Are any of the principals, partners, officers, directors, stockholders, or employees
aware of any error, omission, unresolved job dispute, or accident involving the discharge, dispersal, seepage, migration, or release of a pollutant(s) or contamination which
may be the basis for a claim under this policy?
Y N
If yes, attach an explanation.
NOTE: If you answered YES to Questions A, B or C, please complete our supplemental application for Expanded Pollution coverage.
23. Indicate the number of joint ventures your firm has participated in during the last accounting year: A. Have you ever participated in a joint venture with a non-architecture or engineering firm? Y N
If yes, please provide details of any unreported projects.
B. Do you require evidence of professional liability insurance from all joint venture partners? Y N
24. A. Does your firm subcontract services to others? Y N
If yes, please identify such services.
B. What is the approximate percentage of your firm’s total gross billings for your past accounting year
(12 months) that is attributable to consultants that maintain professional liability insurance: %; and, to consultants that do not maintain such insurance: %.
NOTE: These percentages will not total 100%.
BUSINESS INFORMATION
25. Does your firm, any subsidiary, parent or other organization related to your firm, or any principal, partner, officer, director or employee have a percentage ownership interest, management, or control of a company engaged in:
A. Actual construction, installation, fabrication or erection Y N
B. Design/Build Y N
C. Development, sale or lease of computer software to others Y N
D. Real estate development Y N
E. Manufacture, sale, leasing or distribution of any product, process or
patented production process. Y N
If answer to A, B, C, D or E is yes, please provide full details on a separate sheet, including a description
of the services performed, the relationship of parties involved, construction values involved and fees billed. Also enclose sample contract(s).
26. A. Does your firm or any principal, partner, officer, director or shareholder of your firm or an immediate family member of any such person have more than a 15% combined ownership interest or act as the managing partner in any entity or project for which
professional services have been or are to be rendered? Y N
B. Does your firm render services on behalf of any other entity in which any principal, partner, officer, director or shareholder of your firm or an immediate family member
of such person is a partner, officer, director, shareholder or employee? Y N
C. Is your firm controlled, owned by or associated with or does your firm control or
own any other entity? Y N
If yes, please provide full details on a separate sheet.
27. Has your firm ever been party to any acquisition, consolidation, dissolution, merger,
change in name or change in business organization? Y N
If yes, please provide full particulars on a separate sheet, listing each firm name in chronological order and specify the date of the change, and include claims information for each firm name.
28. Has your firm or any subsidiary or predecessor firm ever filed for or been in receivership
or bankruptcy under a Chapter 7 or 11? Y N
If yes, please explain:
NEW APPLICANT INFORMATION ONLY
29. Please provide full name and professional qualifications on all principals, partners, directors or officers of current firm(s) and dates of employment (registrations and degrees, date and place acquired). If previously a principal, partner, director or officer of another firm, indicate firm name and employment dates.
30. Have any claims been made or legal action been brought in the past ten years (or made earlier and still pending) against your firm, its predecessor(s) or any past or present
principal, partner, officer, director, shareholder or employee? Y N
If yes, provide the following information for each claim on a separate sheet:
A. Date of claim F. Defense attorney’s or insurance company’s
B. Claimant or plaintiff evaluation of exposure/potential liability C. Allegations G. If closed, total amount paid for indemnity
D. Demand or amount of claim and defense costs
E. Insurance company reserve, if any H. Deductible applicable 31. After inquiry, do any of the principals, partners, officers, directors, shareholders or
employees have knowledge of any error, omission, unresolved job dispute (including owner-contractor disputes), accident or any other circumstance that is or could be the
basis for a claim under the proposed insurance policy? Y N
If yes, on a separate sheet please give details of this situation, including name of project and claimant, dates, nature of situation and amount of damages.
NOTE: The policy of insurance being applied for will not respond to any claim or circumstance identified, or that should have been identified, in Questions 30 and 31.
32. Please provide total gross billings for each of the past 5 years.
$ $ $ $ $
(most recent)
33. On a separate sheet, please list your ten largest projects in terms of construction value during the past five years. Provide name, location, type, client, nature of services rendered and status.
34. A. Has any insurer declined, cancelled or refused to renew any similar insurance for
your firm or any predecessor firm? (N/A in Missouri) If yes, please give details. Y N
B. Do you or any subsidiary or predecessor firm have any current outstanding
professional liability deductible obligations? Y N
If yes, please give exact amount owed to insurance company and, if a payment schedule is in place, the amount and dates of repayments on a separate sheet.
C. Has any similar insurance been issued to any of the firms named in Question 1 or persons named in Question 27? If yes, please complete the following for at least the last five years:
Company Policy # Limit Deductible Dates Premium
1. $
2. $
3. $
4. $
5. $
D. Retroactive coverage date in current policy: E. Do you have first dollar defense coverage? Y N
Warning — New York Residents
Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000, and the stated value of the claim for each such violation.
Fraud Prevention — Ohio Warning
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Fraud Prevention – Florida Warning
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony in the third degree.
Fraud Prevention – Colorado Warning
It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
I/We hereby declare that the above statements and particulars are true to the best of my/our knowledge and that I/we have not suppressed or mis-stated any material facts and I/we agree that this application shall be the basis of the contract with the insurance company.
It is understood and agreed that the completion of this application does not bind the insurance company to sell nor the applicant to purchase the insurance.
Name of Principal, Partner or Officer
(Type or Print)
Title
Signature Date
(Principal, Partner or Officer)
NOTE: This application must be reviewed, signed and dated by a principal, partner or officer of the applicant firm.
